Account Setup – WeCare Pharmacy

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This field is for validation purposes and should be left unchanged.

Are you a new or existing client?(Required)

New Client

Existing Client

Organization/Clinic Name(Required)

Organization/Clinic NPI

Owner Name(Required)

First Last

Contact Name(Required)

This is the best person to contact for any office or ordering questions/concerns

First Last

Primary Office Phone Number(Required)

Primary Fax

Primary Email(Required)

Order Shipping Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is the Business/Billing address the same as the shipping address?(Required)

Yes

Business Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card #(Required)

Expiration Date(Required)

CVV(Required)

Zip Code(Required)

Shipping Notification Email(Required)

Do you want your patients to be able to receive SMS from the Pharmacy?(Required)

Yes

Do you want your patients to be able to receive shipment notifications?(Required)

Yes

Prescriber Information(Required)

First Last

Is this the medical director?(Required)

Yes

Credential Classification(Required)

Office Phone(Required)

Provider's Personal Phone(Required)

Provider's Email(Required)

This is the email that will be linked to the ordering platform invitation with Pharmetika

NPI Number(Required)

DEA Number(Required)

if not applicable, write in N/A

State license number(Required)

Your unique credential number that gives you authority to practice in this state; NOT your drivers license

State License Expiration Date(Required)

DEA Expiration Date

Licensing State(Required)

Upload License(s)(Required)

Upload scanned copies of licenses.

Max. file size: 300 MB.

Does this prescriber have any additional state licenses that you would like us to have on file? 1/2(Required)

Yes

Name(Required)

First Last

Credential Classification(Required)

Office Phone(Required)

Provider’s Personal Phone(Required)

Provider’s Email(Required)

This is the email that will be linked to the ordering platform invitation with Pharmetika

NPI Number(Required)

State License(Required)

DEA Number(Required)

if not applicable, write in N/A

State License Expiration Date(Required)

DEA Expiration Date

Licensing State(Required)

Upload License(s)(Required)

Upload scanned copies of licenses.

Max. file size: 300 MB.

Does this prescriber have any additional state licenses that you would like us to have on file? 2/2(Required)

Yes

Name(Required)

First Last

Credential Classification(Required)

Office Phone(Required)

Provider’s Personal Phone(Required)

Provider’s Email(Required)

This is the email that will be linked to the ordering platform invitation with Pharmetika

NPI Number(Required)

State License(Required)

DEA Number(Required)

State License Expiration Date(Required)

DEA Expiration Date

Licensing State(Required)

Upload License(s)(Required)

Max. file size: 300 MB.

Upload scanned copies of licenses.

Are there any additional prescribers at this location? 1/4(Required)

Yes

Prescriber Information(Required)

First Last

Is this the medical director?(Required)

Yes

Credential Classification(Required)

Office Phone(Required)

Provider's Personal Phone(Required)

Provider's Email(Required)

This is the email that will be linked to the ordering platform invitation with Pharmetika

NPI Number(Required)

DEA Number(Required)

if not applicable, write in N/A

State license number(Required)

Your unique credential number that gives you authority to practice in this state; NOT your drivers license

State License Expiration Date(Required)

DEA Expiration Date

Licensing State(Required)

Upload License(s)(Required)

Upload scanned copies of licenses.

Max. file size: 300 MB.

Does this prescriber have any additional state licenses that you would like us to have on file? (1)(Required)

Yes

Name(Required)

First Last

Credential Classification(Required)

Office Phone(Required)

Provider’s Personal Phone(Required)

Provider’s Email(Required)

This is the email that will be linked to the ordering platform invitation with Pharmetika

NPI Number(Required)

State License(Required)

DEA Number(Required)

if not applicable, write in N/A

State License Expiration Date(Required)

DEA Expiration Date

Licensing State(Required)

Upload License(s)(Required)

Upload scanned copies of licenses.

Max. file size: 300 MB.

Are there any additional prescribers at this location? 2/4(Required)

Yes

Prescriber Information(Required)

First Last

Is this the medical director?(Required)

Yes

Credential Classification(Required)

Office Phone(Required)

Provider's Personal Phone(Required)

Provider's Email(Required)

This is the email that will be linked to the ordering platform invitation with Pharmetika

NPI Number(Required)

DEA Number(Required)

if not applicable, write in N/A

State license number(Required)

Your unique credential number that gives you authority to practice in this state; NOT your drivers license

State License Expiration Date(Required)

DEA Expiration Date

Licensing State(Required)

Upload License(s)(Required)

Upload scanned copies of licenses.

Max. file size: 300 MB.

Does this prescriber have any additional state licenses that you would like us to have on file? (2)(Required)

Yes

Name(Required)

First Last

Credential Classification(Required)

Office Phone(Required)

Provider's Personal Phone(Required)

Provider’s Email(Required)

This is the email that will be linked to the ordering platform invitation with Pharmetika

NPI Number(Required)

State License(Required)

DEA Number(Required)

if not applicable, write in N/A

State License Expiration Date(Required)

DEA Expiration Date

Licensing State(Required)

Upload License(s)(Required)

Upload scanned copies of licenses.

Max. file size: 300 MB.

Are there any additional prescribers at this location? 3/4(Required)

Yes

Prescriber Information(Required)

First Last

Is this the medical director?(Required)

Yes

Credential Classification(Required)

Office Phone(Required)

Provider's Personal Phone(Required)

Provider's Email(Required)

This is the email that will be linked to the ordering platform invitation with Pharmetika

NPI Number(Required)

DEA Number(Required)

if not applicable, write in N/A

State license number(Required)

Your unique credential number that gives you authority to practice in this state; NOT your drivers license

State License Expiration Date(Required)

DEA Expiration Date(Required)

Licensing State(Required)

Upload License(s)(Required)

Upload scanned copies of licenses.

Max. file size: 300 MB.

Does this prescriber have any additional state licenses that you would like us to have on file? (3)(Required)

Yes

Name(Required)

First Last

Credential Classification(Required)

Office Phone(Required)

Provider’s Personal Phone(Required)

Provider’s Email(Required)

This is the email that will be linked to the ordering platform invitation with Pharmetika

NPI Number(Required)

State License(Required)

DEA Number(Required)

if not applicable, write in N/A

State License Expiration Date(Required)

DEA Expiration Date

Licensing State(Required)

Upload License(s)(Required)

Upload scanned copies of licenses.

Max. file size: 300 MB.

Are there any additional prescribers at this location? 4/4(Required)

Yes

Prescriber Information(Required)

First Last

Is this the medical director?(Required)

Yes

Credential Classification(Required)

Office Phone(Required)

Provider's Personal Phone(Required)

Provider's Email(Required)

This is the email that will be linked to the ordering platform invitation with Pharmetika

NPI Number(Required)

DEA Number(Required)

if not applicable, write in N/A

State license number(Required)

Your unique credential number that gives you authority to practice in this state; NOT your drivers license

State License Expiration Date(Required)

DEA Expiration Date(Required)

Licensing State(Required)

Upload License(s)(Required)

Upload scanned copies of licenses.

Max. file size: 300 MB.

Does this prescriber have any additional state licenses that you would like us to have on file? (4)(Required)

Yes

Name(Required)

First Last

Credential Classification(Required)

Office Phone(Required)

Provider’s Personal Phone(Required)

Provider’s Email(Required)

This is the email that will be linked to the ordering platform invitation with Pharmetika

NPI Number(Required)

State License(Required)

DEA Number(Required)

if not applicable, write in N/A

State License Expiration Date(Required)

DEA Expiration Date(Required)

Licensing State(Required)

Upload License(s)(Required)

Upload scanned copies of licenses.

Max. file size: 300 MB.

Username(Required)

Password(Required)

Enter Password Confirm Password

Signature(Required)

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